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Collins C, Bongiovanni T. Disparities in Access, Management and Outcomes of Critically Ill Adult Patients with Trauma. Crit Care Clin 2024; 40:659-670. [PMID: 39218479 DOI: 10.1016/j.ccc.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Despite legal protections guaranteeing care for patients with trauma, disparities exist in patient outcomes. We review disparities in patient management and outcomes related to insurance status, race and ethnicity, and gender for patients with trauma in the preadmission, in-hospital, and postdischarge settings. We highlight groups understudied and either underrepresented or unrepresented in national trauma databases-including American Indians/Alaska Natives, non-English preferred patients, and patients with disabilities. We call for more study of these groups and of upstream factors affecting the reviewed demographics to measure and improve outcomes for these vulnerable populations.
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Affiliation(s)
- Caitlin Collins
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA, USA.
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Visco ZR, Chaudry E, Hudson JS, Lim MR. Assessing Healthcare Equity in Orthopaedic Surgery: An Analysis of Over 24,000 Surgical Cases. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202409000-00008. [PMID: 39284006 PMCID: PMC11407820 DOI: 10.5435/jaaosglobal-d-24-00240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Accepted: 07/17/2024] [Indexed: 09/19/2024]
Abstract
INTRODUCTION Health disparities have been widely studied in the primary care and surgical settings. The purpose of this study was to examine surgical access disparities for orthopaedic surgical cases performed at a large academic health center by comparing the relationship between patient demographic factors and surgical wait time. METHODS A total of 24,778 orthopaedic surgical cases from 2018 to 2022 at a public, tertiary care, Level I trauma center were retrospectively analyzed to assess for surgical timing disparities based on patient-specific factors, including race, sex, language, and socioeconomic status. RESULTS Elective surgical cases were completed with an average surgical wait time of 28.11 ± 26.34 days. Urgent surgical cases were completed with an average surgical wait time of 1.23 ± 1.50 days. Patient race, sex, language, and socioeconomic status had no effect on surgical wait time for urgent case scheduling. Female patients had longer average wait times in elective cases, whereas race had a weak association with increased wait time. Two-factor interaction analysis showed no multifactorial effects of patient demographic factors on surgical wait time. Patient race and socioeconomic status were associated with increased distance from surgical sites, although increased distance did not correlate with increased surgical wait time. CONCLUSION Patient demographic factors did not demonstrate clinically notable associations with surgical timing in this patient cohort, in contrast to previous studies demonstrating the effects of race and socioeconomic status on healthcare outcomes and access. Race and socioeconomic status did correlate with increased distance from surgical centers although distance from surgical sites did not correlate with surgical wait time. This contributes to previous literature on healthcare equity and indicates that surgical wait time may not contribute to the known healthcare inequalities seen in minority and marginalized patients.
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Affiliation(s)
- Zachary R Visco
- From the Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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Silverstein LA, Moser DK, Rayens MK. Nurse-Sensitive Indicators as Predictors of Trauma Patient Discharge Disposition. J Trauma Nurs 2024; 31:189-195. [PMID: 38990874 DOI: 10.1097/jtn.0000000000000797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
BACKGROUND About 3.5 million trauma patients are hospitalized every year, but 35%-40% require further care after discharge. Nurses' ability to affect discharge disposition by minimizing the occurrence of nurse-sensitive indicators (catheter-associated urinary tract infection [CAUTI], central line-associated bloodstream infection [CLABSI], and hospital-acquired pressure injury [HAPI]) is unknown. These indicators may serve as surrogate measures of quality nursing care. OBJECTIVE The purpose of this study was to determine whether nursing care, as represented by three nurse-sensitive indicators (CAUTI, CLABSI, and HAPI), predicts discharge disposition in trauma patients. METHODS This study was a secondary analysis of the 2021 National Trauma Data Bank. We performed logistic regression analyses to determine the predictive effects of CAUTI, CLABSI, and HAPI on discharge disposition, controlling for participant characteristics. RESULTS A total of n = 29,642 patients were included, of which n = 21,469 (72%) were male, n = 16,404 (64%) were White, with a mean (SD) age of 44 (14.5) and mean (SD) Injury Severity Score of 23.2 (12.5). We created four models to test nurse-sensitive indicators, both individually and compositely, as predictors. While CAUTI and HAPI increased the odds of discharge to further care by 1.4-1.5 and 2.1 times, respectively, CLABSI was not a statistically significant predictor. CONCLUSIONS Both CAUTI and HAPI are statistically significant predictors of discharge to further care for patients after traumatic injury. High-quality nursing care to prevent iatrogenic complications can improve trauma patients' long-term outcomes.
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Affiliation(s)
- Lily A Silverstein
- Author Affiliations: College of Nursing, University of Kentucky, Lexington, Kentucky (Ms. Silverstein and Drs. Moser and Rayens)
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Campbell BR, Rooney AS, Krzyzaniak A, Lee JJ, Carroll AN, Calvo RY, Peck KA, Martin MJ, Bansal V, Sise MJ, Krzyzaniak MJ. To the point: Utility of laparoscopy for operative management of stabbing abdominal trauma. Am J Surg 2024; 231:125-131. [PMID: 38309996 DOI: 10.1016/j.amjsurg.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/20/2023] [Accepted: 01/24/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Algorithms for managing penetrating abdominal trauma are conflicting or vague regarding the role of laparoscopy. We hypothesized that laparoscopy is underutilized among hemodynamically stable patients with abdominal stab wounds. METHODS Trauma Quality Improvement Program data (2016-2019) were used to identify stable (SBP ≥110 and GCS ≥13) patients ≥16yrs with stab wounds and an abdominal procedure within 24hr of admission. Patients with a non-abdominal AIS ≥3 or missing outcome information were excluded. Patients were analyzed based on index procedure approach: open, therapeutic laparoscopy (LAP), or LAP-conversion to open (LCO). Center, clinical characteristics and outcomes were compared according to surgical approach and abdominal AIS using non-parametric analysis. RESULTS 5984 patients met inclusion criteria with 7 % and 8 % receiving therapeutic LAP and LCO, respectively. The conversion rate for patients initially treated with LAP was 54 %. Compared to conversion or open, therapeutic LAP patients had better outcomes including shorter ICU and hospital stays and less infection complications, but were younger and less injured. Assessing by abdominal AIS eliminated ISS differences, meanwhile LAP patients still had shorter hospital stays. At time of admission, 45 % of open patients met criteria for initial LAP opportunity as indicated by comparable clinical presentation as therapeutic laparoscopy patients. CONCLUSIONS In hemodynamically stable patients, laparoscopy remains infrequently utilized despite its increasing inclusion in current guidelines. Additional opportunity exists for therapeutic laparoscopy in trauma, which appears to be a viable alternative to open surgery for select injuries from abdominal stab wounds. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Bryan R Campbell
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Alexandra S Rooney
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Andrea Krzyzaniak
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Joseph J Lee
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Alyssa N Carroll
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Richard Y Calvo
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Kimberly A Peck
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Matthew J Martin
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Vishal Bansal
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Michael J Sise
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
| | - Michael J Krzyzaniak
- Division of Trauma and Acute Care Surgery, Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
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Goddard SD, Jarman MP, Hashmi ZG. Societal Burden of Trauma and Disparities in Trauma Care. Surg Clin North Am 2024; 104:255-266. [PMID: 38453300 DOI: 10.1016/j.suc.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Trauma imposes a significant societal burden, with injury being a leading cause of mortality worldwide. While numerical data reveal that trauma accounts for millions of deaths annually, its true impact goes beyond these figures. The toll extends to non-fatal injuries, resulting in long-term physical and mental health consequences. Moreover, injury-related health care costs and lost productivity place substantial strain on a nation's economy. Disparities in trauma care further exacerbate this burden, affecting access to timely and appropriate care across various patient populations. These disparities manifest across the entire continuum of trauma care, from prehospital to in-hospital and post-acute phases. Addressing these disparities and improving access to quality trauma care are crucial steps toward alleviating the societal burden of trauma and enhancing equitable patient outcomes.
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Affiliation(s)
- Sabrina D Goddard
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 622, Birmingham, AL 35294, USA
| | - Molly P Jarman
- The Department of Surgery, Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, One Brigham Circle,1620 Tremont Street, Suite 2-016, Boston, MA 02120, USA
| | - Zain G Hashmi
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 622, Birmingham, AL 35294, USA.
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Silver CM, Thomas AC, Reddy S, Kirkendoll S, Nathens AB, Issa N, Patel PP, Plevin RE, Kanzaria HK, Stey AM. Morbidity and Length of Stay After Injury Among People Experiencing Homelessness in North America. JAMA Netw Open 2024; 7:e240795. [PMID: 38416488 PMCID: PMC10902734 DOI: 10.1001/jamanetworkopen.2024.0795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/08/2024] [Indexed: 02/29/2024] Open
Abstract
Importance Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown. Objective To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS). Design, Setting, and Participants This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023. Exposures People experiencing homelessness were identified using the TQP's alternate home residence variable. Main Outcomes and Measures Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms. Results Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients (P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]). Conclusions and Relevance The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.
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Affiliation(s)
- Casey M. Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Arielle C. Thomas
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Susheel Reddy
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Avery B. Nathens
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nabil Issa
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Purvi P. Patel
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | | | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
| | - Anne M. Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Balas M, Vasiliu D, Austria G, Felfeli T. Demographic trends of patients undergoing ophthalmic surgery in Ontario, Canada: a population-based study. BMJ Open Ophthalmol 2023; 8:e001253. [PMID: 37278413 PMCID: PMC10230992 DOI: 10.1136/bmjophth-2023-001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/18/2023] [Indexed: 06/07/2023] Open
Abstract
OBJECTIVE In this study, we investigated the demographic trends of patients undergoing ophthalmic surgeries based on geographic region, priority level, and sex. METHODS AND ANALYSIS This population-based retrospective cohort study used the Ontario Health Wait Times Information System (WTIS) database from 2010 to 2021. The WTIS contains non-emergent surgical case volume and wait time data for 14 different regions, three priority levels (high, medium and low) and six ophthalmic subspecialty procedures. RESULTS Over the study period, on average 83 783 women and 65 555 men underwent ophthalmic surgery annually in Ontario. Overall, women waited an aggregate mean of 4.9 days longer than men to undergo surgery, and this disparity persisted across all geographic and priority stratifications. The average age at the time of surgery has been increasing slowly at a rate of 0.02 years/year (95% CI 0.00 to 0.05), with women being 0.6 years older than men overall. CONCLUSION These findings indicate that women have consistently longer wait times than men. The results of this study may be a sign of systemic sex-based differences that could be affecting women who need to be further explored for health equity.
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Affiliation(s)
- Michael Balas
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Diana Vasiliu
- Health System Intelligence Team, Health System Performance & Support Portfolio, Ontario Health, Toronto, Ontario, Canada
| | - Gener Austria
- Health System Intelligence Team, Health System Performance & Support Portfolio, Ontario Health, Toronto, Ontario, Canada
| | - Tina Felfeli
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- The Institute of Health Policy Management and Evaluation (IHPME), University of Toronto, Ontario, Canada, Canada
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Warner RL, Crandall M. Sex Disparities in Trauma Care-Why Are the Women Waiting? JAMA Surg 2022; 157:617. [PMID: 35583900 DOI: 10.1001/jamasurg.2022.1551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rachel L Warner
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville
| | - Marie Crandall
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville
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